The following are key points to remember from this American Heart Association Scientific Statement on cardio-oncology rehabilitation to manage cardiovascular outcomes in cancer patients and survivors:

1. The elevated cardiovascular disease (CVD) risk in cancer patients and survivors is thought to be a result of both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness—specifically cancer survivors living at least 5 years beyond diagnosis have a 1.3- to 3.6-fold increased risk of CV-specific mortality and a 1.7- to 18.5-fold increased incidence of CVD risk factors such as hypertension, diabetes mellitus, and dyslipidemia compared with age-matched counterparts with no cancer history.
2. The direct and indirect adverse effects of anticancer treatment affect the entire cardiovascular-skeletal muscle axis—for example, patients with breast cancer who are 40-50 years of age have a mean cardiorespiratory fitness level that is 30-32% lower than that of age-matched healthy sedentary control subjects.
3. A limited but growing number of studies have investigated the feasibility and utility of cardiac rehabilitation (CR) to deliver exercise interventions to cancer patients and survivors. The authors of this Scientific Statement, therefore, have developed guidelines including indications and safety check for Cardio-Oncology Rehabilitation (CORE).
4. American Society of Clinical Oncology (ACO) criteria for those considered at increased CVD risk and to be considered for CR include: (1) Therapy with high-dose anthracycline (e.g., doxorubicin ≥250 mg/m², epirubicin ≥600 mg/m²) or high-dose radiotherapy ≥30 Gy when the heart is in the treatment field or lower-dose anthracycline in combination with lower dose radiotherapy; and (2) Therapy with lower-dose anthracycline or trastuzumab alone plus the presence of ≥2 risk factors (smoking, hypertension, diabetes mellitus, obesity, dyslipidemia), older age (≥60 years) at cancer treatment, or compromised cardiac function (history of myocardial infarction, borderline or low left ventricular ejection fraction, moderate valvular disease); or therapy with lower-dose anthracycline followed by trastuzumab.
5. Referral for CORE by the treating provider (such as oncologist, internist, cardiologist) is not driven by a specific point in the cancer continuum but rather by a patient’s underlying risk of cardiac dysfunction (based on the ACO clinical practice guideline), cardiac symptoms, or CVD history. Referrals to CORE flow can occur at the time of active therapy, in the survivorship setting when prior exposures are reviewed, or at any time after a cancer diagnosis in patients with existing CVD or in patients with cancer who develop cardiac symptoms.
6. The CORE approach includes patient assessment, nutrition counseling, weight management, blood pressure management, lipid/lipoprotein management, management of diabetes mellitus, tobacco cessation, psychosocial management, and counseling on physical activity and exercise training.
7. The type and duration of treatment are highly individualized, as is the optimal time to begin a patient-specific rehabilitation program.
8. CORE can be delivered either at center- or at home-based exercise programs, and this statement recommends consideration of patient preference, safety, and efficacy.
9. This Scientific Statement is a first step to pave the way for reimbursement for patients with cancer within the CR model.
10. Research needed to move toward referral and reimbursement of CORE among cancer patients and survivors includes:

• Developing and conveying the evidence base for CORE to patients and families, clinicians, health systems, payers, and employers;
• Demonstrating which patients are most likely to benefit and, when possible, showing improved economic outcomes (e.g., downstream healthcare use, ability to return work);
• Identifying the most effective, efficient, and patient-centric delivery practices in varied settings to quickly adopt what program components work;
• Testing the impact of CORE on cardiac-specific outcomes in patients with cancer (often, these efforts to implement best practices highlight significant gaps in evidence, providing a great opportunity to engage health services researchers, particularly experts in the implementation of science and patient-reported outcomes);
• Creating automatic or opt-out referral systems and stratifying participation data by cancer type, stage, and cardiac risk level to help ensure participation by all who can benefit; and
• Defining and testing the effects of embedding a small set of metrics in quality reporting and performance programs, ideally in both fee-for-service models and value-based arrangements.

Perspective: The authors of this comprehensive Scientific Statement need to be congratulated for their proactive ‘CORE’ approach to preventative cardio-oncology. The cardio-oncology community now can use this as a template to move forward with preventing CVD and improving overall health in cancer patients and survivors.

Keywords: Anthracyclines, Blood Pressure, Breast Neoplasms, Cardiac Rehabilitation, Cardiotoxicity, Diabetes Mellitus, Doxorubicin, Dyslipidemias, Epirubicin, Exercise, Exercise Therapy, Heart Failure, Hypertension, Incidence, Lipids, Lipoproteins, Medical Oncology, Myocardial Infarction, Neoplasms, Obesity, Primary Prevention, Referral and Consultation, Risk Factors, Smoking, Tobacco Use Cessation, Weight Gain

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